Tuesday, June 02, 2009

On Health Care Reform

I'll be back to my my normal blogging in a little bit. I just wanted to blog, a moment, about an approach that seems to work in both cutting costs and in improving health care. It is the model that produces the best results in the world, happens to be working in the United States and produces higher quality and lower costs.

This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.

When you look across the spectrum from Grand Junction to McAllen—and the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.

….[this is just an excerpt] ....

… isn’t going to solve this problem. Nor will changing the person who writes him the check.

This last point is vital. Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Here’s how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some “skin in the game,” and then they’ll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. You get McAllen.

Also, on the same topic,

The cause of the American health paradox is American inequality. America is more unequal than other countries. Everywhere, in every country, the powerful prefer the status quo but in America the rich and elite are especially powerful relative to the poor, so the status quo is especially entrenched and innovation especially well-squelched. America has a lot of health problems building up unsolved. Perhaps the most obvious is obesity, which affects the poor far more than the rich. The further the rich from the poor — that is, the more inequality — the more the rich can ignore it. And they have: The healthcare establishment’s record on prevention and treatment of obesity is terrible. Staggeringly bad.

In one tiny example, when I proposed a rat experiment to test an idea behind the Shangri-La Diet, I was denied permission by the UC Berkeley Animal Care and Use Committee: My idea couldn’t possibly be true, I was told. Had there been plenty of poor people on the committee, instead of none, I think the outcome would have been different. Problems such as depression, allergies, autoimmune disorders, and autism are likewise building up with no real progress being made. An example of a real solution is home glucose monitoring for diabetes. This came from outside the healthcare establishment — from Richard Bernstein, an engineer with diabetes.